Perioperative dexamethasone administration and risk of bleeding following tonsillectomy in children: a randomized controlled trial.

CONTEXT: Corticosteroids are commonly given to children undergoing tonsillectomy to reduce postoperative nausea and vomiting; however, they might increase the risk of perioperative and postoperative hemorrhage. OBJECTIVE: To determine the effect of dexamethasone on bleeding following tonsillectomy in children. DESIGN, SETTING, AND PATIENTS: A multicenter, prospective, randomized, double-blind, placebo-controlled study at 2 tertiary medical centers of 314 children aged 3 to 18 years undergoing tonsillectomy without a history of bleeding disorder or recent corticosteroid medication use and conducted between July 15, 2010, and December 20, 2011, with 14-day follow-up. We tested the hypothesis that dexamethasone would not result in 5% more bleeding events than placebo using a noninferiority statistical design. INTERVENTION: A single perioperative dose of dexamethasone (0.5 mg/kg; maximum dose, 20 mg), with an equivalent volume of 0.9% saline administered to the placebo group. MAIN OUTCOME MEASURES: Rate and severity of posttonsillectomy hemorrhage in the 14-day postoperative period using a bleeding severity scale (level I, self-reported or parent-reported postoperative bleeding; level II, required inpatient admission for postoperative bleeding; or level III, required reoperation to control postoperative bleeding). RESULTS: One hundred fifty-seven children (median [interquartile range] age, 6 [4-8] years) were randomized into each study group, with 17 patients (10.8%) in the dexamethasone group and 13 patients (8.2%) in the placebo group reporting bleeding events. In an intention-to-treat analysis, the rates of level I bleeding were 7.0% (n = 11) in the dexamethasone group and 4.5% (n = 7) in the placebo group (difference, 2.6%; upper limit 97.5% CI, 7.7%; P for noninferiority = .17); rates of level II bleeding were 1.9% (n = 3) and 3.2% (n = 5), respectively (difference, -1.3%; upper limit 97.5% CI, 2.2%; P for noninferiority < .001); and rates of level III bleeding were 1.9% (n = 3) and 0.6% (n = 1), respectively (difference, 1.3%; upper limit 97.5% CI, 3.8%; P for noninferiority = .002). CONCLUSIONS: Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with excessive, clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5%. Increased subjective (level I) bleeding events caused by dexamethasone could not be excluded because the noninferiority threshold was crossed. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01415583.

Age-related changes in the composition and mechanical properties of human nasal cartilage.

Nasal cartilage is widely used in reconstructive surgery for the replacement of soft tissue defects and nasal reconstruction procedures. The ability to shape harvested tissue and the performance in the transplant site are related to the mechanical properties of nasal cartilage. Several studies have documented changes in composition and mechanical properties of other cartilages with age, but little is known about these processes in nasal cartilage. In this study, 45 human nasal septum specimens were gathered from patients 15-60 years of age after reconstructive surgery. Samples were cut to 6 mm in diameter and tested in confined compression to determine equilibrium modulus and hydraulic permeability and analyzed for glycosaminoglycan and hydroxyproline content. Equilibrium modulus decreased significantly with increasing donor age (P<0.01) while hydraulic permeability increased significantly (P<0.02). Glycosaminoglycan (GAG) content decreased significantly with age (P<0.05), while hydroxyproline content showed a slight, but not significant, increase with age (P>0.2). These trends are qualitatively similar to those observed in articular cartilage, suggesting the existence of a systemic process of cartilage degradation that is independent of mechanical loading. Further, the relationships between biochemical composition and mechanical properties were age-dependent, with cartilage from patients less than 30 years of age showing greater dependence of equilibrium modulus and hydraulic permeability on GAG and hydroxyproline content. This suggests that changes in matrix organization may accompany changes in tissue composition.